Orthopedic Coding Alert

Question: How do I code for a bilateral lumbar laminectomy at L5-S1 (Level 5, Segment 1) with excision of a recurrent lumbar disc herniation on the left L5-S1 and decompression of the S1 nerve root?

California Subscriber

Answer: Code 63042 (laminotomy [hemilaminectomy], with decompression of nerve root[s], including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disk, re-exploration, single interspace; lumbar) is correct for the surgery you have described. Note that the narrative for this code indicates that it includes both decompression of the nerve (in your case, the S1 nerve) and excision of the herniated disk (in your case, the L5-S1 disk).

You may append modifier -50 (bilateral procedure) to 63042 to indicate a bilateral procedure. If your physicians perform many spinal surgeries, you may want to invest in Common Coding Scenarios for Spine Procedure & Injection Techniques, a helpful coding guide published by the North American Spine Society.